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241. Fact Sheet on Patient Safety Indicators (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1b_combo_psifactsheet.pdf
     October 01, 2015 - Year PSI 02 Death Rate in Low-Mortality Diagnosis- Related Groups (DRGs) 0.32 0347 2012 PSI 03 Pressure … Thrombosis Rate 4.99 0450 2012 PSI 13 Postoperative Sepsis Rate 9.61 PSI 14 Postoperative Wound … Laceration Rate X 1.89 0345 2012 PSI 16 Transfusion Reaction Count X N/A* 0349 2012 PSI 17 Birth Trauma … Rate – Injury to Neonate 1.89 PSI 18 Obstetric Trauma Rate – vaginal delivery with instrument … 133.19 PSI 19 Obstetric Trauma Rate – vaginal delivery without instrument 20.97 PSI 90

242. 7. Tools and Resources | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/tools-resources.html
     January 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

243. Tool 3 Continued | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/red/toolkit/contactsheet.html
     March 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

244. Tool 6 (continued) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool6ref.html
     July 01, 2018 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

245. Tool 1F: Organizational Readiness Checklist | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/organization-readiness.html
     January 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

246. Tool 3D: Hazard Report Form | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/hazard-report-form.html
     January 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

247. Tool 3P: Best Practices Checklist | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/best-practices.html
     January 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

248. Tool 2G: Managing Change Checklist | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/manage-change-checklist.html
     January 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

249. Contact Sheet (2) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/red/toolkit/contactsheet2.html
     March 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

250. Fall Prevention Program Implementation Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/implementation-guide/index.html
     September 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

251. Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure Ulcers in Nursing Home Environments (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Teigland.pdf
     March 01, 2004 - observed, “Medicare is spending billions to treat preventable (fall) injuries…at an average cost of … Medicare could realize substantial savings if these injuries could be prevented.”15 Prevention of pressure … billion.17 Falls and pressure ulcers are often avoidable. … average cost of $1,272 per injury14 and assuming conservatively that one out of ten falls results in injury … Preventing Falls and Pressure Ulcers 85 12. Dyck MJ.

252. IQI, PSI, AND PDI RATES GENERATED BY THE AHRQ WINDOWS QI SOFTWARE (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2b_combo_ratesgenbywin.pdf
     March 01, 2016 - Rate 0 0 - 0.0006572 PDI1 PDI #1 Accidental Puncture or Laceration Rate 0 0 - 0.00053522 PDI2 PDI #2 Pressure … Count 0 - - - PSI2 PSI #2 Death Rate in Low-Mortality DRGs 8 132 0.06060606 0.00028197 PSI3 PSI #3 Pressure … Rate – Injury to Neonate 0 0 - 0.00210694 PSI18 PSI #18 Obstetric Trauma Rate – Vaginal Delivery With … Diagnosis Related Groups (DRGs) 8 132 0.060606 0.001046 57.95983 0.000282 0.016343 0.007641 PSI #3 Pressure … Rate - Injury to Neonate 0.002107 PSI #18 Obstetric Trauma Rate - Vaginal Delivery With

253. Appendix C6: Falls Assessment Report Sample | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/apcfigtxt6.html
     December 01, 2017 - Patient Safety Patient Safety Resources by Setting Long Term Care Resources Injuries … Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … ( ) Postural hypotension ≥20 mm Hg drop in systolic pressure with position change … https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/apcfigtxt6.html

254. Selected Best Practices and Suggestions for Improvement (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4e_combo_psi08-postophipfx-bestpractices.pdf
     May 20, 2016 - In 2008 the Centers for Medicaid & Medicare Services (CMS) identified falls and trauma—including fractures—as … Prevention Protocol Use a standardized fall prevention protocol to help reduce falls and associated injury … /fallspx/fallspxmanual.pdf http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Transforming care at the bedside how-to guide: reducing patient injuries from falls.http://www.ihi.org … High blood pressure and bone-mineral loss in elderly white women: a prospective study.

255. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - 2 In 2010 an HHS Office of the Inspector General (OIG) team identified the rate of harm—that is, injuries … The estimate for deaths associated with pressure ulcers was based primarily on the paper by Zhan and … Zhan and Miller estimated that excess mortality due to pressure ulcers was 72 deaths per 1,000 pressure … This estimate is based on analysis of data from HCUP identifying injuries in 7.45 million hospital discharge … For example, pressure ulcers had a high baseline prevalence, and excess mortality attributed to pressure

256. Tool 3K: Algorithm for Mobilizing Patients | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/algorithm.html
     January 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Exclusion criteria: unstable vital signs, orthostatic by blood pressure or pulse criteria, specific

257. Final Progress Report: Producing Evidence: Coordination within a Multiteam System Makes Healthcare Safer (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/jones2-report.pdf
     January 01, 2024 - ,3 with an average associated excess cost of $7,000 per injury.4 Regardless of injury, falling can lead … .35 Consequently, randomized controlled trials of individual processes, such as use of bed/chair pressure … Supervisor/Manager Expectations & Actions Promoting Patient Safety (α = .92) 83 80 .88 Whenever pressure … REFINE (REducing Falls in In-patieNt Elderly) using bed and bedside chair pressure sensors linked to … Circumstances of patient falls and injuries in 9 hospitals in a Midwestern healthcare system.

258. Chapter 3. Outline the Evidence and Identify Best Practices | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/vtguide/guide3.html
     February 01, 2016 - Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … associated with a very high risk of VTE include abdominal or pelvic surgery for cancer, multiple major trauma … Examples include craniotomy, traumatic brain injury, spinal cord injury repair, major trauma, plastic … use, ideally used for 18 hours or more. 4 Prophylaxis for Knee Arthroscopy and Isolated Lower Leg Injuries … The same recommendation applies to patients with isolated lower leg injuries distal to the knee that

259. Appendix, Develop a Flowchart of Your Current Medication Reconciliation Process | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-5.html
     July 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … for each of the patient's current medications documented (i.e., documenting plan to continue blood pressure

260. Fallpxtool2D (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool2d.docx
     January 28, 2013 - Monthly falls analysis by: location and time of fall shift and day of week type of injury … consequences of falls High-risk medications, sleep hygiene measures for management of anxiety Low blood pressure